Late anemia is a well-recognized complication of Rhesus hemolytic disease of the newborn (HDN). T... more Late anemia is a well-recognized complication of Rhesus hemolytic disease of the newborn (HDN). The incidence of Rhesus HDN is declining, with a tendency for more severely affected pregnancies to be managed in specialist centres. Consequently, many paediatric departments may see relatively few affected infants with comparatively mild disease, and the risk of late anemia in such cases may not always be appreciated. Two cases of infants born with evidence of Rhesus isoimmunization noted at birth and encountering no immediate problems other than mild hyperbilirubinemia are described. After an uneventful early neonatal course, both infants were discharged without follow-up and presented in the second to third weeks of life with severe, life-threatening anemia, leading to neurological sequelae in one case. The importance of close surveillance, including hemoglobin measurements, in all infants with Rhesus hemolytic disease, irrespective of initial severity, is reiterated.
C entral venous catheters are essential for providing preterm and critically ill neonates long-te... more C entral venous catheters are essential for providing preterm and critically ill neonates long-term intravenous access for nutritional support and medication administration; however, they also place neonates at risk for catheter-related bloodstream infections (CRBSI). Recent estimates of CRBSI rates in neonatal intensive care units (NICUs) range from 3.5 per 1000 central-line days in infants weighing >2500 g to 9.1 per 1000 central-line days in infants weighing ≤1000 g (1). Campaigns to reduce CRBSI (2-3) have included evidencebased practice 'bundles' composed of several interventions including hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal site selection and prompt removal of unnecessary central lines. Bundles have been shown to effectively decrease the incidence of CRBSI (4-5); however, it is not clear which component of the bundle is the most effective. The use of a checklist promotes compliance with best practices during central-line insertion and, thus, may be one of the more important components of the bundle.
2016 IEEE International Conference on Healthcare Informatics (ICHI), 2016
In this paper, we introduce a novel dynamic visual analytic tool called the Cohort Relative Align... more In this paper, we introduce a novel dynamic visual analytic tool called the Cohort Relative Aligned Dashboard (CoRAD). We present the design components of CoRAD, along with alternatives that lead to the final instantiation. We also present an evaluation involving expert clinical researchers, comparing CoRAD against an existing analytics method. The results of the evaluation show CoRAD to be more usable and useful for the target user. The relative alignment of physiologic data to clinical events were found to be a highlight of the tool. Clinical experts also found the interactive selection and filter functions to be useful in reducing information overload. Moreover, CoRAD was also found to allow clinical researchers to generate alternative hypotheses and test them in vivo.
Methods, Models, and Computation for Medical Informatics
In this paper, the authors present a framework to support multidimensional analysis of real-time ... more In this paper, the authors present a framework to support multidimensional analysis of real-time physiological data streams and clinical data. The clinical context for the case study demonstration is neonatal intensive care, focusing specifically on the detection of episodes of central apnoea, a clinically significant problem. The model accounts for the multidimensional and real-time nature of apnoea of prematurity and the associated clinical rules. The framework demonstration includes: 1) defining rules that quantify concurrent behaviours between multiple synchronous data streams and asynchronous data values; 2) designing UML models to define present practice event processing for episodes of apnoea; 3) translating the model in SPADE to enable the deployment within the real-time processing layer of the Artemis platform, which utilizes IBM’s InfoSphere Streams; 4) demonstrating knowledge discovery with simple and complex temporal abstractions of the data streams; and 5) presenting re...
The SNOMED C T® Ju ly 2006 release was systematically examined using the CliniClue® terminology b... more The SNOMED C T® Ju ly 2006 release was systematically examined using the CliniClue® terminology browser to identify SNOMED terms that might be relevant for the structured representation of respiratory disorders of the newborn infant. Three neonatologists evaluated 348 candidate terms for inclusion in a reference set. Two hun dred and eighty-eight (83%) terms were selected for inclusion. Most of
This paper presents a framework for process mining in critical care. The framework uses the CRISP... more This paper presents a framework for process mining in critical care. The framework uses the CRISP-DM model, extended to incorporate temporal and multidimensional aspects (CRISP-TDM n), combined with the Patient Journey Modeling Architecture (PaJMa), to provide a structured approach to knowledge discovery of new condition onset pathophysiologies in physiological data streams. The approach is based on temporal abstraction and mining of physiological data streams to develop process flow mappings that can be used to update patient journeys; instantiated in critical care within clinical practice guidelines. We demonstrate the framework within the neonatal intensive care setting, where we are performing clinical research in relation to pathophysiology within physiological streams of patients diagnosed with late onset neonatal sepsis. We present an instantiation of the framework for late onset neonatal sepsis, using CRISP-TDM n for the process mining model and PaJMa for the knowledge representation.
The success of respiratory syncytial virus (RSV) prophylaxis programs is partially dependent upon... more The success of respiratory syncytial virus (RSV) prophylaxis programs is partially dependent upon meticulous tracking of at risk infants, and excellent data management. We designed and built an integrated, shared, user-driven but infant-centric data management application that enables an infants healthcare provider to determine an infants RSV prophylaxis status throughout the RSV season. The security and confidentiality of each infants information is protected by rigorous integrity constraints that have been integrated into the database schema.
Ligation of a patent ductus arteriosus can lead to severe cardiorespiratory compromise in preterm... more Ligation of a patent ductus arteriosus can lead to severe cardiorespiratory compromise in preterm infants. This report reviews the postoperative course of a patient with significant cardiorespiratory instability following surgical ligation of the patent ductus arteriosus and presents a framework for enhanced cardiovascular care in this population. A preterm infant, born at 24 wk gestation underwent ligation of a large haemodynamically significant ductus arteriosus after failure of 2 courses of indomethacin. He developed systemic hypotension, which was aggressively treated with high doses of multiple cardiotropic agents. After 10 hr of refractory hypotension, the addition of hydrocortisone normalized blood pressure. This article outlines preprocedural categorization of infants according to ductal illness severity which facilitates the risk assignment for postoperative deterioration, development of clinical guidelines specific to the likely haemodynamic changes, enhanced role of funct...
SNOMED CT ® is the most sophisticated reference terminology currently available for the represent... more SNOMED CT ® is the most sophisticated reference terminology currently available for the representation of healthcare. An unforeseen consequence of the opportunistic evolutionary process for SNOMED CT may be that some terms for disorders of specialised clinical domains are not represented within the terminology. The SNOMED CT July 2006 release was systematically examined using the CliniClue ® terminology browser to
The pharmacokinetics of intravenous vancomycin was studied in 20 preterm infants (gestational age... more The pharmacokinetics of intravenous vancomycin was studied in 20 preterm infants (gestational age, 26.5 weeks +/- 2.6 weeks [standard deviation]; birthweight, 880 +/- 340 g). At the time of the studies their postconceptional age was 36.4 +/- 4.5 weeks. The drug was infused over 30 min in a dose between 9.2 and 18 mg/kg. A highly significant correlation existed between postconceptional age or body weight and vancomycin t1/2 and clearance. Serum creatinine concentrations correlated with vancomycin t1/2 and clearance. Serum creatinine tended to decrease with increasing postconceptional age. Based on the excellent correlation between age (or weight) and vancomycin pharmacokinetics, dose and dose-interval recommendations are presented.
analyzed. A higher proportion of patients in the later cohort received antenatal steroids and had... more analyzed. A higher proportion of patients in the later cohort received antenatal steroids and had lower acuity of illness on admission. Unadjusted analyses revealed reduction in mortality (unadjusted odds ratio (UAOR): 0.83, 95% confidence interval (CI): 0.63, 0.98), severe retinopathy (UAOR: 0.68, 95% CI: 0.50 to 0.92), but increase in bronchopulmonary dysplasia (UAOR: 1.61, 95% CI: 1.39 to 1.86) and patent ductus arteriosus (UAOR: 1.22, 95% CI: 1.07 to 1.39). Adjusted analyses revealed increases in the later cohort for bronchopulmonary dysplasia (adjusted odds ratio (AOR): 1.88, 95% CI: 1.60 to 2.20) and severe neurological injury (AOR: 1.49, 95% CI: 1.22 to 1.80). However, the ascertainment methods for neurological findings and ductus arteriosus differed between the two time periods. Conclusion: Improvements in prenatal care has resulted in improvement in the quality of care, as reflected by reduced severity of illness and mortality. However, after adjustment of prenatal factors, no improvement in any of the outcomes was observed and on the contrary bronchopulmonary dysplasia increased. There is need for identification and application of postnatal strategies to improve outcomes of extreme preterm infants.
Systemic hypotension is common in very low birthweight preterm infants but the nature of the prec... more Systemic hypotension is common in very low birthweight preterm infants but the nature of the precipitating cause may be unclear. Targeted neonatal echocardiography (TnEcho) is being increasingly used to support hemodynamic decisions in the neonatal intensive care unit (NICU), including identifying impairments in the transitional circulation of preterm infants, providing timely re-evaluation after institution of therapies and evaluating the placement of indwelling catheters. We present a case of a preterm infant with systemic hypotension and low cardiac output secondary to a large transatrial shunt induced by a malpositioned umbilical venous catheter. Repositioning of the line led to resolution of the hemodynamic disturbance and clinical instability, highlighting the utility of TnEcho in the NICU.
Background The realm of pathological entities can be subdivided into pathological dispositions, p... more Background The realm of pathological entities can be subdivided into pathological dispositions, pathological processes, and pathological structures. The latter are the bearer of dispositions, which can then be realized by their manifestations — pathologic processes. Despite its ontological soundness, implementing this model via purpose-oriented domain ontologies will likely require considerable effort, both in ontology construction and maintenance, which constitutes a considerable problem for SNOMED CT, presently the largest biomedical ontology. Results We describe an ontology design pattern which allows ontologists to make assertions that blur the distinctions between dispositions, processes, and structures until necessary. Based on the domain upper-level ontology BioTop, it permits ascriptions of location and participation in the definition of pathological phenomena even without an ontological commitment to a distinction between these three categories. An analysis of SNOMED CT rev...
Background: Infants with esophageal atresia (EA), omphalocele, and anorectal malformation (ARM) o... more Background: Infants with esophageal atresia (EA), omphalocele, and anorectal malformation (ARM) often have associated congenital heart disease. Recognition of significant cardiac defects, which compromise patient well-being in the perioperative period, is essential before going to the operating room. However, urgent echocardiography may be unavailable, and surgery may therefore be delayed in some cases. We wished to determine if routine echocardiography is necessary for neonates with these diagnoses, or if appropriate patients could be selected. Methods: Retrospective review of all infants admitted to the neonatal intensive care unit with EA, omphalocele, or ARM for 5 years (2003-2008). Clinically relevant findings in the cardiovascular examination (murmur, tachycardia, abnormal 4 limb blood pressure, cyanosis, shock), abnormalities in respiratory examination (intubation, tachypnea, desaturations), or abnormal chest x-ray (cardiomegaly, abnormal pulmonary vasculature) were documented. Cardiac defects were categorized according to their clinical impact as major or minor to differentiate those disorders which may influence timing of surgical intervention. Results: Eighty-six infants were identified (33 EA, 21 omphalocele, 32 ARM). Thirty-seven (42.9%) patients had congenital heart disease on echocardiography evaluation, of which 11 (12.7%) were classified as major and 26 (30.2%) were minor. The sensitivity, specificity, positive predictive value, and negative predictive value of abnormal clinical and radiologic combined assessment for a major cardiac defect were 100% (95% confidence interval [CI], 0.76-1), 64% (95% CI, 0.61-0.64), 28% (95% CI, 0.22-0.29), and 100% (95% CI, 0.94-1.00), respectively. Conclusions: Normal clinical and radiologic examination predicted absence of a significant cardiac abnormality on echocardiography in 100% of cases. We conclude that routine echocardiography before embarking on surgical intervention may not always be necessary but should be reserved for infants with abnormal clinical and/or radiologic findings.
responsive if ΔPCCO increased more than 10% after infusion. The variation of CO estimated with th... more responsive if ΔPCCO increased more than 10% after infusion. The variation of CO estimated with the proposed indices was positively correlated to ΔPCCO (ΔCOSA: r = 0.56, P b .05; ΔCOLM: r = 0.60, P b .05). Bland-Altman analysis showed that the PPV values estimated by the monitor (PPV_PiCCO) were consistent with the indices computed according to the definition. The average value of the differences was close to zero, and the SD of the differences was less than 5%. Both PPV and SVV indices, provided by the PiCCO monitor as well as calculated by the proposed algorithms, resulted in significant differences in the maneuvers classified as responsive (R) compared with those classified as nonresponsive (NR). As expected, lower values of the indices corresponded to lower or no increase of CO. Both PPV_PiCCO and PPV were significantly correlated with ΔPCCO (P b .05), and the correlation coefficients were as follows: r = 0.54 and r = 0.44, respectively. Conclusions: Our results showed that PPV estimated according to its definition, that is, taking into account the respiratory cycle, and PPV estimated by PiCCO, without using respiratory information, are coherent and very similar. Moreover, PPV and SVV produced good values of sensitivity and specificity in separating the maneuvers.
A lthough methods for continuous quality improvement have been used to improve outcomes, 1-3 some... more A lthough methods for continuous quality improvement have been used to improve outcomes, 1-3 some, such as the National Institutes of Child Health and Human Development Quality Collaborative, 4 have reported little or no affect in neonatal intensive care units (ICUs). These methods have been criticized for being based on intuition and anecdotes rather than on evidence. 5 To address these concerns, researchers have developed methods aimed at improving the use of evidence in quality improvement. Tarnow-Mordi and colleagues, 6 Sankaran and colleagues 7 and others 8-10 have used benchmarking instruments 6,8,11 to show risk-adjusted variations in outcomes in neonatal ICUs. Synnes and colleagues 12 reported that variations in the rates of intraventricular hemorrhage could be attributed to practice differences. MacNab and colleagues 13 showed how multi level modelling methods can be used to identify practice differences associated with variations in outcomes for targeted interventions and to quantify their attributable risks. Building on these results, we developed the Evidence-based Practice for Improving Quality method for continuous quality improvement. This method is based on 3 pillars: the use of evidence from published literature; the use of data from participating hospitals to identify hospital-specific practices for targeted intervention; and the use of a national network to share expertise. By selectively targeting hospital-specific practices for intervention, this method reduces the reliance on intuition and anecdotes that are associated with existing quality-improvement methods. Our objective was to evaluate the efficacy of the Evidencebased Practice for Improving Quality method by conducting a prospective cluster randomized controlled trial to reduce nosocomial infection and bronchopulmonary dysplasia among infants born at 32 or fewer weeks' gestation and admitted to 12 Canadian Neonatal Network hospitals 14 over a 36-month period. We hypothesized that the incidence of nosocomial infection would be reduced among infants in ICUs randomized to reduce infection but not among those in ICUs randomized to reduce bronchopulmonary dysplasia. We also hypothesized that the incidence of bronchopulmonary dysplasia would be reduced among infants in the ICUs randomized to reduce this outcome but not among those in ICUs randomized to reduce infections.
We report on a newborn infant with a de novo triplication of the distal segment of 5p: 46,XX,trp(... more We report on a newborn infant with a de novo triplication of the distal segment of 5p: 46,XX,trp(5) (pter-->p14::p14-->p15.33::p15.33--> qter) and multiple congenital anomalies consistent with triplication of 5p. Partial triplication was documented by fluorescence in situ hybridization with a cosmid probe specific for 5p15.2 and microdissected probes obtained from "5pter." Partial duplication of the short arm of chromosome 5 is associated with a specific phenotype that appears to be dependent on the chromosomal region duplicated. Duplication of 5p with breakpoints proximal to band p14 is generally associated with distinct craniofacial malformations, cardiac, renal, intestinal, and limb defects, and mental retardation, whereas duplications with breakpoints distal to 5p14 result in a milder phenotype characterized by minor facial anomalies, developmental delay, and seizures. The most proximal breakpoints of the partial triplication in this patient was estimated to be 5p14, suggesting that a more severe phenotype can occur with triplication of the more distal segment.
Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference, 2008
This paper presents a multi-dimensional approach to knowledge translation, enabling results obtai... more This paper presents a multi-dimensional approach to knowledge translation, enabling results obtained from a survey evaluating the uptake of Information Technology within Neonatal Intensive Care Units to be translated into knowledge, in the form of health informatics capacity audits. Survey data, having multiple roles, patient care scenarios, levels, and hospitals, is translated using a structured data modeling approach, into patient journey models. The data model is defined such that users can develop queries to generate patient journey models based on a pre-defined Patient Journey Model architecture (PaJMa). PaJMa models are then analyzed to build capacity audits. Capacity audits offer a sophisticated view of health informatics usage, providing not only details of what IT solutions a hospital utilizes, but also answering the questions: when, how and why, by determining when the IT solutions are integrated into the patient journey, how they support the patient information flow, and ...
Late anemia is a well-recognized complication of Rhesus hemolytic disease of the newborn (HDN). T... more Late anemia is a well-recognized complication of Rhesus hemolytic disease of the newborn (HDN). The incidence of Rhesus HDN is declining, with a tendency for more severely affected pregnancies to be managed in specialist centres. Consequently, many paediatric departments may see relatively few affected infants with comparatively mild disease, and the risk of late anemia in such cases may not always be appreciated. Two cases of infants born with evidence of Rhesus isoimmunization noted at birth and encountering no immediate problems other than mild hyperbilirubinemia are described. After an uneventful early neonatal course, both infants were discharged without follow-up and presented in the second to third weeks of life with severe, life-threatening anemia, leading to neurological sequelae in one case. The importance of close surveillance, including hemoglobin measurements, in all infants with Rhesus hemolytic disease, irrespective of initial severity, is reiterated.
C entral venous catheters are essential for providing preterm and critically ill neonates long-te... more C entral venous catheters are essential for providing preterm and critically ill neonates long-term intravenous access for nutritional support and medication administration; however, they also place neonates at risk for catheter-related bloodstream infections (CRBSI). Recent estimates of CRBSI rates in neonatal intensive care units (NICUs) range from 3.5 per 1000 central-line days in infants weighing >2500 g to 9.1 per 1000 central-line days in infants weighing ≤1000 g (1). Campaigns to reduce CRBSI (2-3) have included evidencebased practice 'bundles' composed of several interventions including hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal site selection and prompt removal of unnecessary central lines. Bundles have been shown to effectively decrease the incidence of CRBSI (4-5); however, it is not clear which component of the bundle is the most effective. The use of a checklist promotes compliance with best practices during central-line insertion and, thus, may be one of the more important components of the bundle.
2016 IEEE International Conference on Healthcare Informatics (ICHI), 2016
In this paper, we introduce a novel dynamic visual analytic tool called the Cohort Relative Align... more In this paper, we introduce a novel dynamic visual analytic tool called the Cohort Relative Aligned Dashboard (CoRAD). We present the design components of CoRAD, along with alternatives that lead to the final instantiation. We also present an evaluation involving expert clinical researchers, comparing CoRAD against an existing analytics method. The results of the evaluation show CoRAD to be more usable and useful for the target user. The relative alignment of physiologic data to clinical events were found to be a highlight of the tool. Clinical experts also found the interactive selection and filter functions to be useful in reducing information overload. Moreover, CoRAD was also found to allow clinical researchers to generate alternative hypotheses and test them in vivo.
Methods, Models, and Computation for Medical Informatics
In this paper, the authors present a framework to support multidimensional analysis of real-time ... more In this paper, the authors present a framework to support multidimensional analysis of real-time physiological data streams and clinical data. The clinical context for the case study demonstration is neonatal intensive care, focusing specifically on the detection of episodes of central apnoea, a clinically significant problem. The model accounts for the multidimensional and real-time nature of apnoea of prematurity and the associated clinical rules. The framework demonstration includes: 1) defining rules that quantify concurrent behaviours between multiple synchronous data streams and asynchronous data values; 2) designing UML models to define present practice event processing for episodes of apnoea; 3) translating the model in SPADE to enable the deployment within the real-time processing layer of the Artemis platform, which utilizes IBM’s InfoSphere Streams; 4) demonstrating knowledge discovery with simple and complex temporal abstractions of the data streams; and 5) presenting re...
The SNOMED C T® Ju ly 2006 release was systematically examined using the CliniClue® terminology b... more The SNOMED C T® Ju ly 2006 release was systematically examined using the CliniClue® terminology browser to identify SNOMED terms that might be relevant for the structured representation of respiratory disorders of the newborn infant. Three neonatologists evaluated 348 candidate terms for inclusion in a reference set. Two hun dred and eighty-eight (83%) terms were selected for inclusion. Most of
This paper presents a framework for process mining in critical care. The framework uses the CRISP... more This paper presents a framework for process mining in critical care. The framework uses the CRISP-DM model, extended to incorporate temporal and multidimensional aspects (CRISP-TDM n), combined with the Patient Journey Modeling Architecture (PaJMa), to provide a structured approach to knowledge discovery of new condition onset pathophysiologies in physiological data streams. The approach is based on temporal abstraction and mining of physiological data streams to develop process flow mappings that can be used to update patient journeys; instantiated in critical care within clinical practice guidelines. We demonstrate the framework within the neonatal intensive care setting, where we are performing clinical research in relation to pathophysiology within physiological streams of patients diagnosed with late onset neonatal sepsis. We present an instantiation of the framework for late onset neonatal sepsis, using CRISP-TDM n for the process mining model and PaJMa for the knowledge representation.
The success of respiratory syncytial virus (RSV) prophylaxis programs is partially dependent upon... more The success of respiratory syncytial virus (RSV) prophylaxis programs is partially dependent upon meticulous tracking of at risk infants, and excellent data management. We designed and built an integrated, shared, user-driven but infant-centric data management application that enables an infants healthcare provider to determine an infants RSV prophylaxis status throughout the RSV season. The security and confidentiality of each infants information is protected by rigorous integrity constraints that have been integrated into the database schema.
Ligation of a patent ductus arteriosus can lead to severe cardiorespiratory compromise in preterm... more Ligation of a patent ductus arteriosus can lead to severe cardiorespiratory compromise in preterm infants. This report reviews the postoperative course of a patient with significant cardiorespiratory instability following surgical ligation of the patent ductus arteriosus and presents a framework for enhanced cardiovascular care in this population. A preterm infant, born at 24 wk gestation underwent ligation of a large haemodynamically significant ductus arteriosus after failure of 2 courses of indomethacin. He developed systemic hypotension, which was aggressively treated with high doses of multiple cardiotropic agents. After 10 hr of refractory hypotension, the addition of hydrocortisone normalized blood pressure. This article outlines preprocedural categorization of infants according to ductal illness severity which facilitates the risk assignment for postoperative deterioration, development of clinical guidelines specific to the likely haemodynamic changes, enhanced role of funct...
SNOMED CT ® is the most sophisticated reference terminology currently available for the represent... more SNOMED CT ® is the most sophisticated reference terminology currently available for the representation of healthcare. An unforeseen consequence of the opportunistic evolutionary process for SNOMED CT may be that some terms for disorders of specialised clinical domains are not represented within the terminology. The SNOMED CT July 2006 release was systematically examined using the CliniClue ® terminology browser to
The pharmacokinetics of intravenous vancomycin was studied in 20 preterm infants (gestational age... more The pharmacokinetics of intravenous vancomycin was studied in 20 preterm infants (gestational age, 26.5 weeks +/- 2.6 weeks [standard deviation]; birthweight, 880 +/- 340 g). At the time of the studies their postconceptional age was 36.4 +/- 4.5 weeks. The drug was infused over 30 min in a dose between 9.2 and 18 mg/kg. A highly significant correlation existed between postconceptional age or body weight and vancomycin t1/2 and clearance. Serum creatinine concentrations correlated with vancomycin t1/2 and clearance. Serum creatinine tended to decrease with increasing postconceptional age. Based on the excellent correlation between age (or weight) and vancomycin pharmacokinetics, dose and dose-interval recommendations are presented.
analyzed. A higher proportion of patients in the later cohort received antenatal steroids and had... more analyzed. A higher proportion of patients in the later cohort received antenatal steroids and had lower acuity of illness on admission. Unadjusted analyses revealed reduction in mortality (unadjusted odds ratio (UAOR): 0.83, 95% confidence interval (CI): 0.63, 0.98), severe retinopathy (UAOR: 0.68, 95% CI: 0.50 to 0.92), but increase in bronchopulmonary dysplasia (UAOR: 1.61, 95% CI: 1.39 to 1.86) and patent ductus arteriosus (UAOR: 1.22, 95% CI: 1.07 to 1.39). Adjusted analyses revealed increases in the later cohort for bronchopulmonary dysplasia (adjusted odds ratio (AOR): 1.88, 95% CI: 1.60 to 2.20) and severe neurological injury (AOR: 1.49, 95% CI: 1.22 to 1.80). However, the ascertainment methods for neurological findings and ductus arteriosus differed between the two time periods. Conclusion: Improvements in prenatal care has resulted in improvement in the quality of care, as reflected by reduced severity of illness and mortality. However, after adjustment of prenatal factors, no improvement in any of the outcomes was observed and on the contrary bronchopulmonary dysplasia increased. There is need for identification and application of postnatal strategies to improve outcomes of extreme preterm infants.
Systemic hypotension is common in very low birthweight preterm infants but the nature of the prec... more Systemic hypotension is common in very low birthweight preterm infants but the nature of the precipitating cause may be unclear. Targeted neonatal echocardiography (TnEcho) is being increasingly used to support hemodynamic decisions in the neonatal intensive care unit (NICU), including identifying impairments in the transitional circulation of preterm infants, providing timely re-evaluation after institution of therapies and evaluating the placement of indwelling catheters. We present a case of a preterm infant with systemic hypotension and low cardiac output secondary to a large transatrial shunt induced by a malpositioned umbilical venous catheter. Repositioning of the line led to resolution of the hemodynamic disturbance and clinical instability, highlighting the utility of TnEcho in the NICU.
Background The realm of pathological entities can be subdivided into pathological dispositions, p... more Background The realm of pathological entities can be subdivided into pathological dispositions, pathological processes, and pathological structures. The latter are the bearer of dispositions, which can then be realized by their manifestations — pathologic processes. Despite its ontological soundness, implementing this model via purpose-oriented domain ontologies will likely require considerable effort, both in ontology construction and maintenance, which constitutes a considerable problem for SNOMED CT, presently the largest biomedical ontology. Results We describe an ontology design pattern which allows ontologists to make assertions that blur the distinctions between dispositions, processes, and structures until necessary. Based on the domain upper-level ontology BioTop, it permits ascriptions of location and participation in the definition of pathological phenomena even without an ontological commitment to a distinction between these three categories. An analysis of SNOMED CT rev...
Background: Infants with esophageal atresia (EA), omphalocele, and anorectal malformation (ARM) o... more Background: Infants with esophageal atresia (EA), omphalocele, and anorectal malformation (ARM) often have associated congenital heart disease. Recognition of significant cardiac defects, which compromise patient well-being in the perioperative period, is essential before going to the operating room. However, urgent echocardiography may be unavailable, and surgery may therefore be delayed in some cases. We wished to determine if routine echocardiography is necessary for neonates with these diagnoses, or if appropriate patients could be selected. Methods: Retrospective review of all infants admitted to the neonatal intensive care unit with EA, omphalocele, or ARM for 5 years (2003-2008). Clinically relevant findings in the cardiovascular examination (murmur, tachycardia, abnormal 4 limb blood pressure, cyanosis, shock), abnormalities in respiratory examination (intubation, tachypnea, desaturations), or abnormal chest x-ray (cardiomegaly, abnormal pulmonary vasculature) were documented. Cardiac defects were categorized according to their clinical impact as major or minor to differentiate those disorders which may influence timing of surgical intervention. Results: Eighty-six infants were identified (33 EA, 21 omphalocele, 32 ARM). Thirty-seven (42.9%) patients had congenital heart disease on echocardiography evaluation, of which 11 (12.7%) were classified as major and 26 (30.2%) were minor. The sensitivity, specificity, positive predictive value, and negative predictive value of abnormal clinical and radiologic combined assessment for a major cardiac defect were 100% (95% confidence interval [CI], 0.76-1), 64% (95% CI, 0.61-0.64), 28% (95% CI, 0.22-0.29), and 100% (95% CI, 0.94-1.00), respectively. Conclusions: Normal clinical and radiologic examination predicted absence of a significant cardiac abnormality on echocardiography in 100% of cases. We conclude that routine echocardiography before embarking on surgical intervention may not always be necessary but should be reserved for infants with abnormal clinical and/or radiologic findings.
responsive if ΔPCCO increased more than 10% after infusion. The variation of CO estimated with th... more responsive if ΔPCCO increased more than 10% after infusion. The variation of CO estimated with the proposed indices was positively correlated to ΔPCCO (ΔCOSA: r = 0.56, P b .05; ΔCOLM: r = 0.60, P b .05). Bland-Altman analysis showed that the PPV values estimated by the monitor (PPV_PiCCO) were consistent with the indices computed according to the definition. The average value of the differences was close to zero, and the SD of the differences was less than 5%. Both PPV and SVV indices, provided by the PiCCO monitor as well as calculated by the proposed algorithms, resulted in significant differences in the maneuvers classified as responsive (R) compared with those classified as nonresponsive (NR). As expected, lower values of the indices corresponded to lower or no increase of CO. Both PPV_PiCCO and PPV were significantly correlated with ΔPCCO (P b .05), and the correlation coefficients were as follows: r = 0.54 and r = 0.44, respectively. Conclusions: Our results showed that PPV estimated according to its definition, that is, taking into account the respiratory cycle, and PPV estimated by PiCCO, without using respiratory information, are coherent and very similar. Moreover, PPV and SVV produced good values of sensitivity and specificity in separating the maneuvers.
A lthough methods for continuous quality improvement have been used to improve outcomes, 1-3 some... more A lthough methods for continuous quality improvement have been used to improve outcomes, 1-3 some, such as the National Institutes of Child Health and Human Development Quality Collaborative, 4 have reported little or no affect in neonatal intensive care units (ICUs). These methods have been criticized for being based on intuition and anecdotes rather than on evidence. 5 To address these concerns, researchers have developed methods aimed at improving the use of evidence in quality improvement. Tarnow-Mordi and colleagues, 6 Sankaran and colleagues 7 and others 8-10 have used benchmarking instruments 6,8,11 to show risk-adjusted variations in outcomes in neonatal ICUs. Synnes and colleagues 12 reported that variations in the rates of intraventricular hemorrhage could be attributed to practice differences. MacNab and colleagues 13 showed how multi level modelling methods can be used to identify practice differences associated with variations in outcomes for targeted interventions and to quantify their attributable risks. Building on these results, we developed the Evidence-based Practice for Improving Quality method for continuous quality improvement. This method is based on 3 pillars: the use of evidence from published literature; the use of data from participating hospitals to identify hospital-specific practices for targeted intervention; and the use of a national network to share expertise. By selectively targeting hospital-specific practices for intervention, this method reduces the reliance on intuition and anecdotes that are associated with existing quality-improvement methods. Our objective was to evaluate the efficacy of the Evidencebased Practice for Improving Quality method by conducting a prospective cluster randomized controlled trial to reduce nosocomial infection and bronchopulmonary dysplasia among infants born at 32 or fewer weeks' gestation and admitted to 12 Canadian Neonatal Network hospitals 14 over a 36-month period. We hypothesized that the incidence of nosocomial infection would be reduced among infants in ICUs randomized to reduce infection but not among those in ICUs randomized to reduce bronchopulmonary dysplasia. We also hypothesized that the incidence of bronchopulmonary dysplasia would be reduced among infants in the ICUs randomized to reduce this outcome but not among those in ICUs randomized to reduce infections.
We report on a newborn infant with a de novo triplication of the distal segment of 5p: 46,XX,trp(... more We report on a newborn infant with a de novo triplication of the distal segment of 5p: 46,XX,trp(5) (pter-->p14::p14-->p15.33::p15.33--> qter) and multiple congenital anomalies consistent with triplication of 5p. Partial triplication was documented by fluorescence in situ hybridization with a cosmid probe specific for 5p15.2 and microdissected probes obtained from "5pter." Partial duplication of the short arm of chromosome 5 is associated with a specific phenotype that appears to be dependent on the chromosomal region duplicated. Duplication of 5p with breakpoints proximal to band p14 is generally associated with distinct craniofacial malformations, cardiac, renal, intestinal, and limb defects, and mental retardation, whereas duplications with breakpoints distal to 5p14 result in a milder phenotype characterized by minor facial anomalies, developmental delay, and seizures. The most proximal breakpoints of the partial triplication in this patient was estimated to be 5p14, suggesting that a more severe phenotype can occur with triplication of the more distal segment.
Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference, 2008
This paper presents a multi-dimensional approach to knowledge translation, enabling results obtai... more This paper presents a multi-dimensional approach to knowledge translation, enabling results obtained from a survey evaluating the uptake of Information Technology within Neonatal Intensive Care Units to be translated into knowledge, in the form of health informatics capacity audits. Survey data, having multiple roles, patient care scenarios, levels, and hospitals, is translated using a structured data modeling approach, into patient journey models. The data model is defined such that users can develop queries to generate patient journey models based on a pre-defined Patient Journey Model architecture (PaJMa). PaJMa models are then analyzed to build capacity audits. Capacity audits offer a sophisticated view of health informatics usage, providing not only details of what IT solutions a hospital utilizes, but also answering the questions: when, how and why, by determining when the IT solutions are integrated into the patient journey, how they support the patient information flow, and ...
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Papers by Andrew James